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  • Question 1 - A 45-year-old man presents with tiredness and central weight gain.
    He underwent pituitary...

    Incorrect

    • A 45-year-old man presents with tiredness and central weight gain.
      He underwent pituitary surgery for a non-functional pituitary tumour two years ago. Although he recovered from his pituitary surgery well, he has been found to have complete anterior hypopituitarism. Accordingly he is receiving stable replacement therapy with testosterone monthly injections, thyroxine and hydrocortisone.
      On examination, there are no specific abnormalities, his vision is 6/9 in both eyes and he has no visual field defects.
      From his notes, you see that he has gained 8 kg in weight over the last six months and his BMI is 31. His blood pressure is 122/72 mmHg.
      Thyroid function tests and testosterone concentrations have been normal. A post-operative MRI scan report shows that the pituitary tumour has been adequately cleared with no residual tissue.

      Which of the following is the most likely cause of his current symptoms?

      Your Answer: Somatisation disorder

      Correct Answer: Growth hormone deficiency

      Explanation:

      The somatotroph cells of the anterior pituitary gland produce growth hormone (GH).
      GH deficiency in adults usually manifests as reduced physical performance and impaired psychological well-being. It results in alterations in the physiology of different systems of the body, manifesting as altered lipid metabolism, increased subcutaneous and visceral fat, decreased muscle mass, decreased bone density, low exercise performance, and reduced quality of life.

    • This question is part of the following fields:

      • Endocrinology
      1
      Seconds
  • Question 2 - A 28-year-old woman is referred to the endocrinology clinic. She has been trying...

    Incorrect

    • A 28-year-old woman is referred to the endocrinology clinic. She has been trying to conceive for the last 3 years without any success. Her prolactin level is 2600 mU/l (normal <360). The Endocrinologist arranges pituitary magnetic resonance imaging (MRI) that demonstrates a microprolactinoma.

      Which two of the following pharmacological agents may be appropriate treatment choices?

      Your Answer: Thioridazine

      Correct Answer: Carbergoline

      Explanation:

      Cabergoline, an ergot derivative, is a long-acting dopamine agonist. It is usually better tolerated than Bromocriptine (BEC), and its efficacy profiles are somewhat superior to those of BEC. It offers the convenience of twice-a-week administration, with a usual starting dose of 0.25 mg biweekly to a maximum dose of 1 mg biweekly. Some studies have shown efficacy even with once-a-week dosing. Cabergoline appears to be more effective in lowering prolactin levels and restoring ovulation. Up to 70% of patients who do not respond to BEC respond to cabergoline.

    • This question is part of the following fields:

      • Endocrinology
      5
      Seconds
  • Question 3 - A 58-year-old psychologist with small cell lung cancer complains of muscle weakness. Each...

    Incorrect

    • A 58-year-old psychologist with small cell lung cancer complains of muscle weakness. Each one of the following are features of Lambert-Eaton syndrome, except:

      Your Answer:

      Correct Answer: Repeated muscle contractions lead to decreased muscle strength

      Explanation:

      In myasthenia gravis, repeated muscle contractions lead to reduced muscle strength. The opposite is however classically seen in the related disorder Lambert-Eaton syndrome. Lambert-Eaton myasthenic syndrome is seen in association with small cell lung cancer, and to a lesser extent breast and ovarian cancer. It may also occur independently as an autoimmune disorder. Lambert-Eaton myasthenic syndrome is caused by an antibody directed against pre-synaptic voltage gated calcium channel in the peripheral nervous system.

    • This question is part of the following fields:

      • Neurology
      0
      Seconds
  • Question 4 - A 20-year-old gentleman presents with drop foot following a sports injury.
    On examination...

    Incorrect

    • A 20-year-old gentleman presents with drop foot following a sports injury.
      On examination there is weakness of ankle dorsiflexion and eversion, and weakness of extension of the big toe. He has some sensory loss restricted to the dorsum of his foot surrounding the base of his big toe. Other examination is within normal limits.
      Where is the most likely site of the lesion?

      Your Answer:

      Correct Answer: Common peroneal nerve at the head of the fibula

      Explanation:

      Peroneal nerve injury is also known as foot drop. The common peroneal nerve supplies the ankle and toe extensor muscle groups as well as sensation over the dorsum of the foot; thus, there is also loss of sensation in these cases.

    • This question is part of the following fields:

      • Neurology
      0
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  • Question 5 - A 60–year-old woman comes to the hospital for chemotherapy for breast cancer.
    On...

    Incorrect

    • A 60–year-old woman comes to the hospital for chemotherapy for breast cancer.
      On examination, her pulse is 120 bpm and regular and BP is 90/60. Her JVP is not seen, her heart sounds are normal, and her chest is clear. There is evidence of a right mastectomy. Abdominal and neurological examination is normal.
      Short synacthen test was ordered and the results came as follows:
      Time (min):
      0,
      30,
      60.
      Cortisol (nmol/l):
      90,
      130,
      145.

      Which two of the following would be your immediate management?

      Your Answer:

      Correct Answer: Intravenous normal saline six-hourly

      Explanation:

      Synacthen test interpretation:
      – Basal Cortisol level should be greater than 180nmol/L
      – 30min or 60min Cortisol should be greater than 420nmol/L (whatever the basal level)
      – The increment should be at least 170nmol/L, apart from in severely ill patients where adrenal output is already maximal.
      The patient’s results show that she has Acute Adrenal Insufficiency
      The guidelines include the following recommendations for emergency treatment:
      Administer hydrocortisone: Immediate bolus injection of 100 mg hydrocortisone intravenously or intramuscularly followed by continuous intravenous infusion of 200 mg hydrocortisone per 24 hours (alternatively, 50 mg hydrocortisone per intravenous or intramuscular injection every 6 h)
      Rehydrate with rapid intravenous infusion of 1000 mL of isotonic saline infusion within the first hour, followed by further intravenous rehydration as required (usually 4-6 L in 24 h; monitor for fluid overload in case of renal impairment and elderly patients)
      Contact an endocrinologist for urgent review of the patient, advice on further tapering of hydrocortisone, and investigation of the underlying cause of the disease, including the diagnosis of primary versus secondary adrenal insufficiency
      Tapering of hydrocortisone can be started after clinical recovery guided by an endocrinologist; in patients with primary adrenal insufficiency, mineralocorticoid replacement must be initiated (starting dose 100 μg fludrocortisone once daily) as soon as the daily glucocorticoid dose is below 50 mg of hydrocortisone every 24 hours

    • This question is part of the following fields:

      • Endocrinology
      0
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  • Question 6 - A 23-year-old woman presents with hirsutism and oligomenorrhea for the last five years....

    Incorrect

    • A 23-year-old woman presents with hirsutism and oligomenorrhea for the last five years. She is very anxious about her irregular menses and worried as her mother was diagnosed with uterine cancer recently. She is a lawyer and does not want to conceive, at least for the next couple of years.
      The examination is essentially normal except for coarse dark hair being noticed under her chin and over her lower back.

      Investigations done during the follicular phase:
      Serum androstenedione 10.1 nmol/l (0.6-8.8),
      Serum dehydroepiandrosterone sulphate 11.6 ىmol/l (2-10),
      Serum 17-hydroxyprogesterone 5.6 nmol/l (1-10),
      Serum oestradiol 220 pmol/l (200-400),
      Serum testosterone 3.6 nmol/l (0.5-3),
      Serum sex hormone binding protein 32 nmol/l (40-137),
      Plasma luteinising hormone 3.3 U/l (2.5-10),
      Plasma follicle-stimulating hormone 3.6 U/l (2.5-10).

      What is the most appropriate treatment?

      Your Answer:

      Correct Answer: Combined OCP

      Explanation:

      This patient has polycystic ovarian syndrome (PCOS). Medical management of PCOS is aimed at the treatment of metabolic derangements, anovulation, hirsutism, and menstrual irregularity.
      First-line medical therapy usually consists of an oral contraceptive to induce regular menses. The contraceptive not only inhibits ovarian androgen production but also increases sex hormone-binding globulin (SHBG) production. The American College of Obstetricians and Gynaecologists (ACOG) recommends the use of combination low-dose hormonal contraceptive agents for long-term management of menstrual dysfunction.
      If symptoms such as hirsutism are not sufficiently alleviated, an androgen-blocking agent may be added. Pregnancy should be excluded before therapy with oral contraceptives or androgen-blocking agents are started.
      First-line treatment for ovulation induction when fertility is desired is clomiphene citrate. Second-line strategies may be equally effective in infertile women with clomiphene citrate–resistant PCOS.

    • This question is part of the following fields:

      • Endocrinology
      0
      Seconds
  • Question 7 - Causes of dilated pupils include which of the following? ...

    Incorrect

    • Causes of dilated pupils include which of the following?

      Your Answer:

      Correct Answer: Ethylene glycol poisoning

      Explanation:

      Ethylene glycol poisoning is the only poison listed that will cause dilation of the pupils whereas all the other listed conditions and poisons will present with small pupils other than in the case of Myotonic dystrophy wherein the patient will present with a cortical cataract.

    • This question is part of the following fields:

      • Neurology
      0
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  • Question 8 - Which one of the following types of thyroid cancer is associated with the...

    Incorrect

    • Which one of the following types of thyroid cancer is associated with the RET oncogene?

      Your Answer:

      Correct Answer: Medullary

      Explanation:

      RET (rearranged during transfection) is a receptor tyrosine kinase involved in the development of neural crest derived cell lineages, kidney, and male germ cells. Different human cancers, including papillary and medullary thyroid carcinomas, lung adenocarcinomas, and myeloproliferative disorders display gain-of-function mutations in RET.
      In over 90% of cases, MEN2 syndromes are due to germline missense mutations of the RET gene.
      Multiple endocrine neoplasias type 2 (MEN2) is an inherited disorder characterized by the development of medullary thyroid cancer (MTC), parathyroid tumours, and pheochromocytoma.

    • This question is part of the following fields:

      • Endocrinology
      0
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  • Question 9 - A 44-year-old hairdresser with a history of myasthenia gravis is admitted to the...

    Incorrect

    • A 44-year-old hairdresser with a history of myasthenia gravis is admitted to the Emergency Department. She is currently taking pyridostigmine, but there has been a significant worsening of her symptoms following antibiotic treatment for a chest infection. On examination she is dyspnoeic and cyanotic with quiet breath sounds in both lungs. Other than respiratory support, what are the two other treatments of choice?

      Your Answer:

      Correct Answer: Plasmapheresis or intravenous immunoglobulins

      Explanation:

      This patient is having a myasthenic crisis. Opinions vary as to whether plasmapheresis or intravenous immunoglobulins should be given first-line. Plasmapheresis usually works much faster, but is more costly due to equipment.
      Myasthenia gravis is an autoimmune disorder resulting in insufficient functioning acetylcholine receptors. Antibodies to acetylcholine receptors are seen in 85-90% of cases. Myasthenia gravis is more common in women (2:1).

    • This question is part of the following fields:

      • Neurology
      0
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  • Question 10 - Which of the following may cause a downbeat nystagmus? ...

    Incorrect

    • Which of the following may cause a downbeat nystagmus?

      Your Answer:

      Correct Answer: Chiari type I malformation

      Explanation:

      Downbeat nystagmus (DBN) suggests a lesion in the lower part of the medulla. Chiari Type I malformation usually presents with symptoms due to brain stem and lower cranial nerve dysfunction, which includes DBN.

    • This question is part of the following fields:

      • Neurology
      0
      Seconds
  • Question 11 - A 66 year-old marketing analyst presents to the respiratory clinic with a 2-month...

    Incorrect

    • A 66 year-old marketing analyst presents to the respiratory clinic with a 2-month history of progressive weakness and shortness of breath. He finds it difficult to stand from sitting, and struggles climbing stairs. He is an ex-smoker with chronic obstructive pulmonary disease (COPD). He had a recent exacerbation one month ago for which he was treated by the GP with a course of oral prednisolone, during which time his weakness transiently improved. On examination, you note a left-sided monophonic wheeze and reduced breath sounds at the left lung base. Blood tests and a chest x-ray are requested.

      Hb 145 g/L
      WCC10.5 109/L,
      Na+136 mmol/L,
      K+ 4.3 mmol/L,
      Urea 6.8 mmol/L,
      Creatinine 93 mmol/L,
      Calcium 2.62 mmol/L,
      Phosphate 1.44 mmol/L,


      Chest x-ray shows hyperinflated lungs, left lower lobe collapse and a bulky left hilum

      What is the most likely cause of this patient's weakness?

      Your Answer:

      Correct Answer: Lambert-Eaton myasthenic syndrome

      Explanation:

      This man has a small-cell lung cancer (SCLC) and associated Lambert-Eaton myasthenic syndrome – a well-recognized paraneoplastic manifestation of SCLC. This classically affects the proximal muscles, especially in the legs, causing difficulty in standing from a seated position and climbing stairs. In contrast to myasthenia gravis, eye involvement is uncommon. Treatment with steroids is often helpful, which explains his transient symptomatic improvement during treatment for his COPD exacerbation. Steroid myopathy does not fit as the symptoms started well before his course of prednisolone. Although the patient is mildly hypercalcaemic, this would not be sufficient to produce his presenting symptoms, although it does reinforce the suspicion of lung malignancy. Motor neurone disease would be unlikely in this context and would not improve with steroids. Myasthenia gravis could produce these symptoms, but in the context of a new lung mass is a less viable diagnosis.

    • This question is part of the following fields:

      • Neurology
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  • Question 12 - A 53 year-old dancer presents to the ED with increasing weakness. She has...

    Incorrect

    • A 53 year-old dancer presents to the ED with increasing weakness. She has no pertinent past medical history aside from a recent diarrhoeal illness, which she attributes to an undercooked chicken meal. Her husband says that she has been unable to get up out of a chair for the past day. Upon examination, there is bilateral limb weakness and areflexia noted, but it is more severe in the lower limbs. You notice that if she lies flat in the bed, her oxygen saturations fall by around 2% on the pulse oximeter and she is unable to perform spirometry. Which of the following represents the most appropriate immediate management of choice in this patient?

      Your Answer:

      Correct Answer: ITU review for consideration of ventilation

      Explanation:

      This woman has a history that is suggestive of Guillain– Barré syndrome. This may be precipitated by Campylobacter, and her history of recent diarrhoeal illness is pointing towards that. Certain features point to a poor prognosis, including rapidity of onset, reduced vital capacity or respiratory failure, age >40 and reduced amplitude of compound muscle action potential. Her inability to perform spirometry and desaturating whilst lying flat are suggestive of impending respiratory muscle weakness. Review for consideration of ventilation is recommended. Further management of choice for Guillain-Barre syndrome is IV immunoglobulins. Steroids have no value in the treatment of the condition.

    • This question is part of the following fields:

      • Neurology
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  • Question 13 - A 40-year-old woman presents with weight loss, palpitations, diarrhoea and cessation of periods....

    Incorrect

    • A 40-year-old woman presents with weight loss, palpitations, diarrhoea and cessation of periods. She has been treated by her GP for anxiety. Examination reveals a single nodule on the left of her thyroid, about 1.5 cm in diameter.
      Thyroid scan shows increased uptake within the nodule with reduced activity throughout the rest of the gland.
      Thyroid function tests showed a free thyroxine of 30 pmol/l (9–25 pmol/l), TSH < 0.05 mU/l (0.5–5).
      Based on these findings, what would be the definitive treatment?

      Your Answer:

      Correct Answer: Radioactive iodine therapy

      Explanation:

      Patients who have autonomously functioning nodules should be treated definitely with radioactive iodine or surgery.
      Na131 I treatment – In the United States and Europe, radioactive iodine is considered the treatment of choice for Toxic Nodular Goitre. Except for pregnancy, there are no absolute contraindications to radioiodine therapy.

    • This question is part of the following fields:

      • Endocrinology
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  • Question 14 - Which of the following is most consistent with achondroplasia? ...

    Incorrect

    • Which of the following is most consistent with achondroplasia?

      Your Answer:

      Correct Answer: May be diagnosed radiologically at birth

      Explanation:

      Achondroplasia is the most common type of short-limb disproportionate dwarfism. A single gene mapped to the short arm of chromosome 4 (band 4p16.3) is responsible for achondroplasia and is transmitted as an autosomal dominant trait. All people with achondroplasia have a short stature.
      Characteristic features of achondroplasia include an average-size trunk, short arms and legs with particularly short upper arms and thighs, limited range of motion at the elbows, and an enlarged head (macrocephaly) with a prominent forehead. Fingers are typically short and the ring finger and middle finger may diverge, giving the hand a three-pronged (trident) appearance. People with achondroplasia are generally of normal intelligence.
      Examination of the infant after birth shows increased front-to-back head size. There may be signs of hydrocephalus. It may be diagnosed radiographically at birth, or becomes obvious within the first year with disparity between a large skull, normal trunk length and short limbs.

    • This question is part of the following fields:

      • Endocrinology
      0
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  • Question 15 - A 33-year-old woman presents to the clinic with chronic fatigue. She has 3...

    Incorrect

    • A 33-year-old woman presents to the clinic with chronic fatigue. She has 3 children and a full-time job and is finding it very difficult to hold everything together. There is no significant past medical history.
      On examination, her BP is 145/80 mmHg and her BMI is 28.
      Investigations show:
      Hb 12.5 g/dL,
      WCC 6.7 x109/L,
      PLT 204 x109/L,
      Na+ 141 mmol/L,
      K+ 4.9 mmol/L,
      Creatinine 120 μmol/L,
      Total cholesterol 5.0 mmol/L,
      TSH 7.8 U/l,
      Free T4 10.0 pmol/l (10-22),
      Free T3 4.9 pmol/l (5-10).

      Which of the following is the most likely diagnosis?

      Your Answer:

      Correct Answer: Subclinical hypothyroidism

      Explanation:

      Elevated TSH (usually 4.5-10.0 mIU/L) with normal free T4 is considered mild or subclinical hypothyroidism.
      Hypothyroidism commonly manifests as a slowing in physical and mental activity but may be asymptomatic. Symptoms and signs are often subtle and neither sensitive nor specific.
      The following are symptoms of hypothyroidism:
      – Fatigue, loss of energy, lethargy
      – Weight gain
      – Decreased appetite
      – Cold intolerance
      – Dry skin
      – Hair loss
      – Sleepiness
      – Muscle pain, joint pain, weakness in the extremities
      – Depression
      – Emotional lability, mental impairment
      – Forgetfulness, impaired memory, inability to concentrate
      – Constipation
      – Menstrual disturbances, impaired fertility
      – Decreased perspiration
      – Paraesthesia and nerve entrapment syndromes
      – Blurred vision
      – Decreased hearing
      – Fullness in the throat, hoarseness
      Physical signs of hypothyroidism include the following:
      – Weight gain
      – Slowed speech and movements
      – Dry skin
      – Jaundice
      – Pallor
      – Coarse, brittle, straw-like hair
      – Loss of scalp hair, axillary hair, pubic hair, or a combination
      – Dull facial expression
      – Coarse facial features
      – Periorbital puffiness
      – Macroglossia
      – Goitre (simple or nodular)
      – Hoarseness
      – Decreased systolic blood pressure and increased diastolic blood pressure
      – Bradycardia
      – Pericardial effusion
      – Abdominal distention, ascites (uncommon)
      – Hypothermia (only in severe hypothyroid states)
      – Nonpitting oedema (myxoedema)
      – Pitting oedema of lower extremities
      – Hyporeflexia with delayed relaxation, ataxia, or both.

    • This question is part of the following fields:

      • Endocrinology
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  • Question 16 - A 69 year-old librarian with motor neuron disease is seen in clinic. Which...

    Incorrect

    • A 69 year-old librarian with motor neuron disease is seen in clinic. Which of the following interventions will have the greatest effect on survival?

      Your Answer:

      Correct Answer: Non-invasive ventilation

      Explanation:

      Motor neuron disease is a neurological condition of unknown cause which can present with both upper and lower motor neuron signs. It rarely presents before age 40 and various patterns of disease are recognised, including amyotrophic lateral sclerosis, progressive muscular atrophy and bulbar palsy.
      Non-invasive ventilation (usually BIPAP) is used at night, with studies having shown a survival benefit of around 7 months. Riluzole prevents stimulation of glutamate receptors, used mainly in amyotrophic lateral sclerosis and has been shown to prolong life by about 3 months.

    • This question is part of the following fields:

      • Neurology
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  • Question 17 - A 61-year old mechanic recently attended A&E, with a 3 month history of...

    Incorrect

    • A 61-year old mechanic recently attended A&E, with a 3 month history of bilateral paraesthesia's and twitching affecting the thumb, first finger and lateral forearm. He denied any trauma. An MRI scan of his spine was performed and revealed cervical canal stenosis with mild cord compression. He was discharged and advised to see his GP for follow-up. Which of the following is the most appropriate initial step in management?

      Your Answer:

      Correct Answer: Refer to spinal surgery services

      Explanation:

      Bilateral median nerve dysfunction is suggestive of degenerative cervical myelopathy (DCM) rather than bilateral carpal tunnel syndrome. DCM should be suspected in elderly patients presenting with limb neurology. This patient’s twitches are probably fibrillations, a sign of lower motor neuron dysfunction.
      Degenerative cervical myelopathy is associated with a delay in diagnosis. It is most commonly misdiagnosed as carpal tunnel syndrome. In one study, 43% of patients who underwent surgery for degenerative cervical myelopathy had been initially diagnosed with carpal tunnel syndrome.
      Management of these patients should be by specialist spinal services (neurosurgery or orthopaedic spinal surgery). Decompressive surgery is the mainstay of treatment and has been shown to stop disease progression. Physiotherapy and analgesia do not replace surgical opinion, though they may be used alongside. Nerve root injections do not have a role in management.

    • This question is part of the following fields:

      • Neurology
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  • Question 18 - A 74-year-old woman is admitted with headaches, polyuria and polydipsia of recent onset....

    Incorrect

    • A 74-year-old woman is admitted with headaches, polyuria and polydipsia of recent onset. She has a history of mastectomy for breast cancer. A CT head scan shows multiple cerebral metastases.

      Her admission biochemistry results are as follows:
      Sodium 153 mmol/l,
      Potassium 4.0 mmol/L,
      Urea 5.0 mmol/L,
      Creatinine 110 micromol/L,
      Glucose 5mmol/l.
      Over the next 24 hours, she has a urinary volume of 4.4 litres and further tests reveal plasma osmolality 320mOsm/kg and urinary osmolality: 254mOsm/kg.

      Which one of the following treatments should be used?

      Your Answer:

      Correct Answer: Desmopressin (DDAVP)

      Explanation:

      Diabetes insipidus (DI) is defined as the passage of large volumes (>3 L/24 hr) of dilute urine (< 300 mOsm/kg). It has the following 2 major forms:
      – Central (neurogenic, pituitary, or neurohypophyseal) DI, characterized by decreased secretion of antidiuretic hormone (ADH; also referred to as arginine vasopressin [AVP])
      – Nephrogenic DI, characterized by decreased ability to concentrate urine because of resistance to ADH action in the kidney
      This patient has the central type from metastases.
      In patients with central DI, desmopressin is the drug of choice. It is a synthetic analogue of antidiuretic hormone (ADH). It is available in subcutaneous, IV, intranasal, and oral preparations. Generally, it can be administered 2-3 times per day. Patients may require hospitalization to establish fluid needs. Frequent electrolyte monitoring is recommended during the initial phase of treatment.

    • This question is part of the following fields:

      • Endocrinology
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  • Question 19 - Which of the following features is not associated with an oculomotor nerve palsy?...

    Incorrect

    • Which of the following features is not associated with an oculomotor nerve palsy?

      Your Answer:

      Correct Answer: Miosis

      Explanation:

      Oculomotor nerve palsy is an eye condition resulting from damage to the third cranial nerve or a branch thereof. A complete oculomotor nerve palsy will result in a characteristic down and out position in the affected eye. This is because the lateral rectus (innervated by the sixth cranial nerve) and superior oblique (innervated by the fourth cranial or trochlear nerve), is unantagonized by the paralyzed superior rectus, inferior rectus and inferior oblique. The affected individual will also have a ptosis, or drooping of the eyelid, and mydriasis (pupil dilation), not miosis.

    • This question is part of the following fields:

      • Neurology
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  • Question 20 - A 30-year-old man with type-1 diabetes mellitus on insulin presents in the A&E...

    Incorrect

    • A 30-year-old man with type-1 diabetes mellitus on insulin presents in the A&E with fever, cough, vomiting and abdominal pain.
      Examination reveals a dry mucosa, decreased skin turgor and a temperature of 37.8 °C.
      Chest examination reveals bronchial breathing in the right lower lobe, and a chest X-ray shows it to be due to a right lower zone consolidation.
      Other investigations show:
      Blood glucose: 35 mmol/L,
      Na+: 132 mmol/L,
      K+: 5.5 mmol/L,
      urea: 8.0 mmol/L,
      creatinine: 120 μmol/L,
      pH: 7.15,
      HCO3: 12 mmol/L,
      p(CO2): 4.6 kPa,
      chloride: 106 mmol/l.
      Urinary ketones are positive (+++).

      The patient is admitted to the hospital and treated. Which of the following should not be used while treating him?

      Your Answer:

      Correct Answer: Bicarbonate

      Explanation:

      Bicarbonate therapy is not indicated in mild and moderate forms of DKA because metabolic acidosis will correct with insulin therapy. The use of bicarbonate in severe DKA is controversial due to a lack of prospective randomized studies. It is thought that the administration of bicarbonate may actually result in peripheral hypoxemia, worsening of hypokalaemia, paradoxical central nervous system acidosis, cerebral oedema in children and young adults, and an increase in intracellular acidosis. Because severe acidosis is associated with worse clinical outcomes and can lead to impairment in sensorium and deterioration of myocardial contractility, bicarbonate therapy may be indicated if the pH is 6.9 or less.

    • This question is part of the following fields:

      • Endocrinology
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  • Question 21 - A 21 year-old software developer undergoes a planned lumbar puncture (LP) as part...

    Incorrect

    • A 21 year-old software developer undergoes a planned lumbar puncture (LP) as part of a neurological investigation for possible multiple sclerosis. During the consent process, she expresses concern about a post-LP headache. What is the mechanism of post-LP headaches?

      Your Answer:

      Correct Answer: Leaking cerebrospinal fluid from the dura

      Explanation:

      Leaking of cerebrospinal fluid from the dura is the most likely explanation for post-lumbar puncture headaches. It is thought that ongoing leak of cerebrospinal fluid (CSF) through the puncture site causes ongoing CSF loss, leading to low pressure. A post-LP headache is typically frontal or occipital and occurs within three days. It is normally associated with worsening on standing and improvement when lying down. Treatment in severe cases includes an epidural blood patch, but most resolve on their own.

    • This question is part of the following fields:

      • Neurology
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  • Question 22 - Which of the following statements regarding restless leg syndrome is not true? ...

    Incorrect

    • Which of the following statements regarding restless leg syndrome is not true?

      Your Answer:

      Correct Answer: It is three times as common in females

      Explanation:

      In restless leg syndrome (RLS), males and females are thought to be equally affected. RLS is a syndrome of spontaneous, continuous lower limb movements that may be associated with paraesthesia. It is extremely common, affecting between 2-10% of the general population and a family history may be present.

    • This question is part of the following fields:

      • Neurology
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  • Question 23 - A 40-year-old man is referred by his general practitioner. He has a family...

    Incorrect

    • A 40-year-old man is referred by his general practitioner. He has a family history of premature cardiovascular disease.
      Cholesterol testing reveals triglyceride levels of 4.2 mmol/l and a high-density lipoprotein (HDL) level of 0.8 mmol/l.
      You advise him to start fibrate therapy.
      Which of the following best describes the mode of action for fibrates?

      Your Answer:

      Correct Answer: They are inhibitors of lipoprotein lipase activity and increase HDL synthesis

      Explanation:

      Treatment with fibrates, a widely used class of lipid-modifying agents, results in a substantial decrease in plasma triglycerides and is usually associated with a moderate decrease in LDL cholesterol and an increase in HDL cholesterol concentrations.
      Evidence from studies is available to implicate 5 major mechanisms underlying the above-mentioned modulation of lipoprotein phenotypes by fibrates:
      1. Induction of lipoprotein lipolysis.
      2. Induction of hepatic fatty acid (FA) uptake and reduction of hepatic triglyceride production.
      3. Increased removal of LDL particles. Fibrate treatment results in the formation of LDL with a higher affinity for the LDL receptor, which is thus catabolized more rapidly.
      4. Reduction in neutral lipid (cholesteryl ester and triglyceride) exchange between VLDL and HDL may result from decreased plasma levels of TRL.
      5. Increase in HDL production and stimulation of reverse cholesterol transport. Fibrates increase the production of apoA-I and apoA-II in the liver, which may contribute to the increase of plasma HDL concentrations and a more efficient reverse cholesterol transport.

    • This question is part of the following fields:

      • Endocrinology
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  • Question 24 - A 72-year-old woman presents with 18 month history of gait ataxia, dysarthria, and...

    Incorrect

    • A 72-year-old woman presents with 18 month history of gait ataxia, dysarthria, and dysphagia.
      On examination there is down beating nystagmus and slurred speech. There is past pointing in both upper limbs and a wide-based ataxic gait. Reflexes and sensation are normal. There is no wasting or fasciculations. Plantar response is flexor bilaterally.
      What is the most likely diagnosis?

      Your Answer:

      Correct Answer: Arnold-Chiari malformation

      Explanation:

      Downbeat nystagmus (DBN) suggests a lesion in the lower part of the medulla. Arnold-Chiari malformation usually presents with symptoms due to brainstem and lower cranial nerve dysfunction such as DBN.

    • This question is part of the following fields:

      • Neurology
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  • Question 25 - A young woman is concerned that she has put on weight since she...

    Incorrect

    • A young woman is concerned that she has put on weight since she was a medical student, as she now no longer finds time to exercise. She decides to try various weight loss tablets temporarily.
      After 2 months, she is successfully losing weight but also has trouble with increased stool frequency, difficulty in climbing stairs and getting up out of chairs. However, she has no problems walking on the flat.
      She also has difficulty in sleeping at the moment but puts that down to the increased frequency of headaches for the past 2 months.

      Which one of the following is the most likely cause of her weakness?

      Your Answer:

      Correct Answer: She is abusing thyroxine tablets

      Explanation:

      Exogenous thyroid hormone use has been associated with episodes of thyroid storm as well as thyrotoxic periodic paralysis.
      It presents with marked proximal muscle weakness in both upper and lower limbs, hypokalaemia and signs of hyperthyroidism.
      Hyperthyroidism generally presents with tachycardia, hypertension, hyperthermia, and cardiac arrhythmias

      Laxatives and diuretics can result in electrolyte abnormalities.
      Medical complications associated with laxatives include chronic diarrhoea which disrupts the normal stool electrolyte concentrations that then leads to serum electrolyte shifts; acutely, hypokalaemia is most typically seen. The large intestine suffers nerve damage from the chronic laxative use that renders it unable to function properly. The normal peristalsis and conduction are affected; the disorder is thought to be secondary to a degeneration of Auerbach’s Plexi. However, it does not cause muscle weakness.

      Insulin tends to cause weight gain, not weight loss.
      Metformin does not cause muscle weakness but can cause headaches.

    • This question is part of the following fields:

      • Endocrinology
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  • Question 26 - A 21-year-old patient is referred to the tertiary neurology clinic because of a...

    Incorrect

    • A 21-year-old patient is referred to the tertiary neurology clinic because of a possible diagnosis of Juvenile Parkinson’s disease. His symptoms began predominantly with dystonia affecting the lower limbs, but he now has more classical signs of older onset Parkinson’s including tremor, bradykinesia, and rigidity.
      You map out his family tree and understand that his sister developed Parkinson’s at the age of 16 but that his parents do not have signs of Parkinson’s.
      Which of the following is the most likely mode of inheritance?

      Your Answer:

      Correct Answer: Autosomal recessive

      Explanation:

      Juvenile Onset Parkinson’s is an autosomal recessive condition that usually presents in late childhood to early adulthood, initially with gait disorders caused by lower limb dystonia that later develops to the more classical signs Parkinson’s.

    • This question is part of the following fields:

      • Neurology
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  • Question 27 - A 72-year-old man presents with chronic back and right hip pain which has...

    Incorrect

    • A 72-year-old man presents with chronic back and right hip pain which has been increasingly affecting him over the past few months. He finds it very difficult to mobilise in the mornings.

      Clinical examination is unremarkable, apart from a limitation of right hip flexion due to pain.
      Investigations show:
      Haemoglobin 12.1 g/dl (13.5-17.7),
      White cell count 8.2 x 109/l (4-11),
      Platelets 200 x 109/l (150-400),
      C reactive protein 9 nmol/l (<10),
      ESR 15 mm/hr (<20),
      Sodium 140 mmol/l (135-146),
      Potassium 3.9 mmol/l (3.5-5),
      Creatinine 92 µmol/l (79-118),
      Alanine aminotransferase 12 U/l (5-40),
      Alkaline phosphatase 724 U/l (39-117),
      Calcium 2.55 mmol/l (2.20-2.67).

      Which of the following is the most likely diagnosis?

      Your Answer:

      Correct Answer: Paget's disease

      Explanation:

      Paget disease is a localized disorder of bone remodelling that typically begins with excessive bone resorption followed by an increase in bone formation. This osteoclastic over activity followed by compensatory osteoblastic activity leads to a structurally disorganized mosaic of bone (woven bone), which is mechanically weaker, larger, less compact, more vascular, and more susceptible to fracture than normal adult lamellar bone.
      Approximately 70-90% of persons with Paget disease are asymptomatic; however, a minority of affected individuals experience various symptoms, including the following:
      – Bone pain (the most common symptom)
      – Secondary osteoarthritis (when Paget disease occurs around a joint)
      – Bony deformity (most commonly bowing of an extremity)
      – Excessive warmth (due to hypervascularity)
      – Neurologic complications (caused by the compression of neural tissues)
      Measurement of serum alkaline phosphatase—in some cases, bone-specific alkaline phosphatase (BSAP)—can be useful in the diagnosis of Paget disease. Elevated levels of urinary markers, including hydroxyproline, deoxypyridinoline, C-telopeptide, and N -telopeptide, may help identify patients with Paget disease.
      Serum calcium and phosphate levels should be within the reference range in patients with Paget disease.

    • This question is part of the following fields:

      • Endocrinology
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  • Question 28 - A 32 year-old active male presents with a three month history of pain...

    Incorrect

    • A 32 year-old active male presents with a three month history of pain in his feet and lower legs. He was previously diagnosed with diabetes at age 14 and treated with insulin. He admits to drinking 30 units of alcohol per week and is a current cannabis smoker. On examination, pain and temperature sensation in his feet are diminished, but joint position and vibratory sensation appear normal. What is the most likely diagnosis?

      Your Answer:

      Correct Answer: Diabetic polyneuropathy

      Explanation:

      The given history suggests a small fibre painful peripheral sensory neuropathy, the most common cause of which is diabetes. Joint position sense and vibratory sensation are carried through large fibres, and therefore are not currently affected. Sensory nerves are affected more often than motor, so reflexes usually remain in tact.

      Vitamin B12 deficiency causes impairment of joint position and vibratory sensation.

      Chronic inflammatory demyelinating polyneuropathy (CIPD) causes a large fibre peripheral neuropathy with areflexia.

      In syringomyelia there is impaired pain and temperature noted in the upper limbs.

      Finally, with alcoholic polyneuropathy, all fibre types are affected (sensory and motor loss). It is usually gradual with long term alcohol abuse and may be accompanied by a nutritional deficiency. In addition, pain is a more dominant feature.

    • This question is part of the following fields:

      • Neurology
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  • Question 29 - Which of the following statements regarding dipeptidyl peptidase-4 inhibitors in the management of...

    Incorrect

    • Which of the following statements regarding dipeptidyl peptidase-4 inhibitors in the management of type 2 diabetes mellitus is correct?

      Your Answer:

      Correct Answer: Do not cause weight gain

      Explanation:

      Several dipeptidyl peptidase-4 (DPP-4) inhibitors are in clinical development; these are orally active and increase levels of active glucagon-like peptide-1 (GLP-1), which in turn increases insulin secretion and reduces glucagon secretion, thereby lowering glucose levels.
      Sitagliptin and vildagliptin both have a long duration of action, allowing once-daily administration. Both sitagliptin and vildagliptin are safe and tolerable with a low risk of hypoglycaemia. In drug-naïve subjects with type 2 diabetes, both sitagliptin and vildagliptin reduce A1C levels by ,1% as monotherapy.

    • This question is part of the following fields:

      • Endocrinology
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  • Question 30 - A 47-year-old hypertensive man presents with difficulty using his right arm, slow walking...

    Incorrect

    • A 47-year-old hypertensive man presents with difficulty using his right arm, slow walking and occasional loss of balance. He has a broad-based gait with cogwheel rigidity and intention tremor of his right arm. His blood pressure is 140/80 mmHg sitting and 100/60 mmHg standing. Which of the following is the most likely diagnosis?

      Your Answer:

      Correct Answer: Multiple system atrophy

      Explanation:

      This patient presents with a combination of akinetic rigid syndrome, cerebellar signs and the suggestion of autonomic features. This is most indicative of a diagnosis of multiple system atrophy.

      Multiple system atrophy (MSA) is a rare neurodegenerative disorder characterized by autonomic dysfunction, tremors, slow movement, muscle rigidity, and postural instability (collectively known as parkinsonism) and ataxia.

    • This question is part of the following fields:

      • Neurology
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